Author: Dr David Glass

A prescription with a difference – the scientific considerations.

Any number of patients in most clinical practices present with infections on a daily basis. These may include urinary tract infections, otitis media, bronchitis, septic wounds, conjunctivitis, tonsilitis, and sometimes more severe infections like pneumonia, pyelonephritis and pelvic infection. Of course, some of these may be viral in origin, but the rest usually either start as bacterial or are secondarily infected. The treatment of choice is an antibiotic if caused by bacteria, and we generally expect to see recovery to full function, if the right medication has been prescribed.

Antibiotics have revolutionised the treatment of infections. Conditions like scarlet fever, rheumatic heart disease, bacterial meningitis, and severe septicaemia from injuries are uncommon in places where quality medical care is readily available. Thanks to vaccinations, better housing, good sanitation, and better nutrition, the scourge of high morbidity and mortality from communicable diseases in much of the world is uncommon, apart from pandemics like influenza, COVID-19 and Ebola.

However, there is another pandemic ravaging our planet, which is not going away with sophisticated hospitals, expensive medicines, or well-trained doctors and nurses. It is called the pandemic of non- communicable diseases, and includes such conditions as atherosclerotic cardiovascular disease, hypertension, diabetes mellitus type 2, obesity, chronic respiratory diseases, dementia and cancer. (1)

“Non-Communicable Diseases (NCDs),…currently pose one of the biggest threats to health and development globally, particularly in low and middle-income countries. It is predicted that unless proven interventions are rapidly implemented in countries, in the short to medium term, healthcare costs will increase exponentially, and severe negative consequences will ensue, not only to individuals and families, but to whole societies and economies. NCDs are already a major burden in South Africa, but without added rigorous and timely action the health and development consequences may well become catastrophic. Immediate and additional, high quality, evidence-based and focussed interventions are needed to promote health, prevent disease, and provide more effective and equitable care and treatment for people living with NCDs at all levels of the health system.” (2).

These were the sobering opening statements on the SA National Department of Health’s NCDs National Strategic Plan draft proposal released on 18 May 2020. The incidence of non-communicable diseases is rising all around the world, especially in developing countries, but also in well-resourced countries. (3) According to experts in our National Department of Health we need to apply “high quality, evidence-based and focussed interventions” to deal with this pandemic.

Historically, the most important way that communicable (infectious) diseases were brought under control was by treating the underlying causes. Surprisingly, this basic principle of treatment has been superseded in the management of NCDs by focusing on dealing with their clinical consequences rather than their causes. A whole raft of pharmaceutical and surgical options and protocols have been developed for managing the complications of NCDs, but these mostly do not address the underlying causes. These interventions are good for the economics of businesses involved in provision of healthcare, but don’t prevent the diseases themselves, and usually only slow their progression. Most doctors have never been taught how to address these underlying causes of NCDs in their medical training.

So, what are the underlying causes? It was back in 1982 that Dr ARP Walker, one of South Africa’s scientific research giants stated: “Diet, physical activity, smoking habits, atmospheric pollution, stresses associated with urbanization and availability of medical services are the main environmental factors that have changed. Alterations in these factors are deemed largely responsible, or even almost wholly responsible, for the changes in disease patterns and the associated mortality patterns that have been described.” (4)

Various approaches have been used to elucidate the problem.

1. Plot the changes in lifestyle – diet, physical activity, stress level, social disruption, addictive behaviours – over the last few decades, and compare these with the rising incidences of NCDs. (4)
2. Examine the effect of industrialisation and globalisation on changes in cultures and compare this with the rising NCD levels in less developed countries. (5) (6) (7)
3. Study large populations over many years and compare rates of NCDs within those populations according to different behaviours: Nurses Health Studies (8) , Adventist Health Studies 1, 2 (9) , European Prospective Investigation into Cancer (EPIC) (10) , Ancel Keys 7 counties study (11) , Blue Zones (12) , Framingham Heart Studies (13) .
4. Study the effects of significant positive behaviour changes in larger populations to determine reductions in risk factors for NCDs: Finland’s North Karelia Project for Cardiovascular disease (14) .
5. Perform prospective controlled studies to establish evidence for statistically significant reduction in complications, and even reversal of diseases through addressing lifestyle issues: Dean Ornish on reversal of coronary atherosclerosis (15) , National Diabetes Prevention Program (16) , Lifestyle Medicine and Diabetes Reversal (17) .

All this evidence points to the power of addressing lifestyle behaviours to prevent, manage, and in many cases reverse the progress of NCDs. There is consensus amongst those who have studied these factors, that the causes relate to: dietary changes associated with industrialisation and globalisation; sedentarism; use of harmful substances; social disruption; unresolved stress; and inadequate sleep. By addressing these factors, “dramatic” impacts have been demonstrated on the course of non-communicable diseases, both individually, as well as on societies. (18,14)

However, this is not as simple as telling someone to do certain actions and to avoid others. There is both an art and a science to motivating behaviour change. That will be the subject of future articles. What is the rational approach when dealing with a patient with diabetes, or dangerously high blood pressure, or angina? Of course, the patient may need pharmacotherapy to bring the blood pressure down, or improve the insulin sensitivity, or improve coronary artery dilatation. And for this they will probably need a prescription or, they may need urgent surgical intervention. But just as important as the pharmaceutical prescription, or emergency surgery, is a discussion of lifestyle changes to address the underlying causes at an appropriate time, and to formulate, in partnership with the patient, what behaviours he/she is willing to adopt toward mitigating or reversing the NCD. This is what is meant by “completing the prescription”. (19)

Dr Dave Glass
MBChB, FCOG(SA), DipIBLM,
Chairman, South African Lifestyle Medicine Association